Received any recent faxed consultation reports from a colleague or diagnostic imaging reports from your local hospital? Most of these are accompanied by a cover sheet. Great in the paper world, however a real challenge when using an EMR. Cover sheets are very useful at separating one fax from another when multiple faxes are received on a single fax machine. They ensure that critical reports are not mistakenly mixed with other faxed information and make the sorting of these reports more efficient and more accurate. Once the fax is correctly sorted and ready for filing in the paper record, the cover sheet can be discarded, leaving just the important information in the patient chart.

However, this is not as simple a process in an EMR. Many EMRs now used fax modems to send and receive patient information. In the majority of cases, the faxed reports are electronically converted into PDF files which can then be tagged and attached in a patient record in the appropriate section or file folder within the EMR. Electronic snapshots of PDFs can also increase the speed with which one can review multiple documents. A miniature image of a PDF can make it easy to differentiate between the type of document you are seeking without actually needing to open the file. For example, EKG vs. Diagnostic Imaging report vs. specialist consultation. If a PDF has a coversheet (which generally is page 1 of the file), all documents look the same in snapshot view as the coversheet is the first to be presented. Removing the coversheet is not a simple process. Using a PDF document editing program (such as Adobe Acrobat), one needs to open the file and delete the cover page, resave the file and then attach it in the patient record. This is an unnecessary extra step that takes time and requires software and expertise.

As the majority of practices begin to use EMRs, could we dispense with cover sheets entirely as a relic of the paper chart? This will make attaching and viewing PDF files a much simpler and clinically more efficient process in the EMR.

This may seem a logical and easy step, however it will need a methodical action plan, contacting all providers and organizations that send faxes to electronic systems. Then convincing them that the cover sheet is no longer necessary and making the changes to the transmission software to ensure that the cover sheets are removed.

What worked well in paper does not necessarily translate effectively into an EMR-based world of clinical practice.

What do you think? Have you had similar problems with cover sheets? Do they get in the way or can you live with the current format in which faxes are sent and received? Add your thoughts by clicking on the 'Comments' link below.

Fax technology slotted in perfectly with paper processes and quickly revolutionized the way that information was communicated. Within a few years of introduction, fax machines were cheap, good quality, and virtually ubiquitous. However, because they were so successfully adopted, faxes also created dependencies in terms of the way that organizations shared information between one another.

In a report by Healthcare IT News, a new study by HIMSS Analytics examined the current state of information exchange among U.S. hospitals and found that if a hospital was not participating in a health information exchange (HIO), 64% of data sharing was conducted via fax. In addition, 63% of the same HIOs processed faxed information into an electronic format via scanning. This is a common phenomenon in physician offices. Reports and related information are transmitted between practices by fax. In those practices, running EMRs, if the faxes are not received electronically using a fax modem, they are scanned into the EMR setting up a repetitive cycle of printing and digitization.

Achieving widespread information exchange means getting beyond the “if it ain’t broke, don’t fix it” thinking that is also prevalent. The first prerequisite is that a viable information exchange option exists; the second, that one is willing to give up existing dependable processes that are an integral part of workflow. Despite producing a lot of paper, fax technology is very efficient and dependable; however, there are ways to integrate faxing effectively into an electronic workflow. If you are not yet using a fax server with your EMR software, or even standalone, this should be seriously considered. In a 2012 article on CanadianEMR, “Do You Need a Fax Server for Your Practice?” this topic was covered in some detail and is well worth reading.

Bottom line: Because we do not yet have widespread data interoperability between different EMRs and between multiple providers and sites within the healthcare system, faxing will likely be around for some time. The best strategy is to optimize your existing setting, integrate electronic faxing into your workflow process, and be prepared to transition tasks that currently require fax technology once other sites are set up for different forms of data exchange.

Converting paper charts during EMR implementation
is generally seen as one of the greatest barriers to switching over a
practice. Chart conversion is a time-consuming and
resource-intensive task; however, there are several things your practice can do
to help shorten and reduce the pain of chart conversion. In order to maximize the benefits of your EMR, you will need to
pre-populate the record with important clinical and
demographic information. The following simple steps will improve your
successful transition from paper charts to an EMR.

Develop a plan that both indentifies the process you will use to
capture the information from your paper charts and establishes realistic
timeframes within which to complete the process. Consider the data that is most frequently going to be clinically
relevant in the treatment of your patients. One of the most common
mistakes is to attempt to input the entire patient chart into a new
system. Not only is this expensive, but also it can end up corrupting the data in the new
system.

Data you will most frequently need include the following: allergies,
current problems, current medications (episodic and long-term meds),
past medical and surgical history, important diagnostic results (e.g.
lab results, pathology, or most recent EKG), consult letters, immunizations, screening
test dates/results, and advance directives.

Here are some tips and best practices for chart conversion:

Review and update your paper charts prior to implementing your EMR.
Irrespective of which EMR you choose, you will need to get your charts
prepared for data input. Organizing the updated clinical data using a
standardized face sheet will streamline your data entry process when you
populate your EMR.

If you have more than one physician in your practice, it is important to agree upon a single standard paper template to collect this
information. This will allow you and your staff to pre-populate summary information and makes
the data you may want to transfer to your EMR more readily accessible
and faster to input into your EMR. It also gets you and your practice used
to documenting your patient visits in a structured manner that will
likely be similar to most EMR systems.

Identify patients who are seen regularly in your practice with
chronic medical conditions or complex care problems. Getting these paper
charts organized and entered into your EMR will allow you to focus on
the clinical encounter when you see that patient. It is much easier to
pre-enter all the complex patient data, which will allow you or your
staff to enter less complex patients on the day they are seen or during
the clinical encounter.

When choosing how to enter the data, remember that discrete
information such as immunizations or labs, if entered as a .pdf or TIFF
file will not populate any of the data fields in your EMR. As a result,
any alerts in your system will not be
reflected in this data.

If you choose to scan all of your old patient records, you will then
be able to move any remaining paper charts off-site and will be able to
reclaim space used for chart storage and utilize that space for other
purposes such as additional examination rooms. If scanned into a
compatible format (e.g. PDF), a copy of each scanned patient record can
be attached in your EMR allowing for quick review of the paper medical
chart if needed.

Establish a clear goal to keep everyone in the practice
motivated. One of the most effective strategies is the “three time rule”
where the physician is allowed to use the patient’s paper chart only
three times (three visits) before the paper chart is retired. After that
point, the chart is still accessible, but — as a deterrent — some
practices charge each physician a small fee per chart.

Have you converted from paper charts to an EMR? Share your experiences by clicking on the “Comments” link below.

Is the quality of documentation better using EMRs or paper? Readers of this blog will be very interested in receiving feedback from physicians and office staff who have been using an EMR for their clinical documentation for a couple of years or more. If you have never used a paper chart, it may be difficult to make the comparison, for example new graduates who have been trained in facilities and practices that only use electronic record systems. However the majority of physicians in clinical practice today will still remember the paper record — some with a sense of nostalgia and others a sense of relief.

There is something elegant about a well-crafted clinical note that tells the story of the patient (whether it be electronic or on paper), particularly if that note can be crafted into a patient summary or referral/consultation letter that accurately describes the patient's clinical problem in a manner that is helpful to the treating physician. Earlier this year, while working in Singapore on a medication project, a colleague lamented to me about the state of clinical documentation. He described a time pre-EMR when physicians would take the utmost care to think about the clinical status of their patients and would painstakingly document their findings including a summary and plan and would integrate lab and diagnostic information into the narrative. In contrast, he felt that the prevalence of electronic clinical documentation systems had made physicians lazy — it was easier to generate a report by selecting checkboxes and date ranges for clinical encounters than ensuring the summary was accurate, logical and clear. It’s all about the building blocks. If you are not inputting quality information, it is difficult to get decent information out of the chart.

Back to the original question. Is the quality of documentation better in one medium vs. the other? From a legibility perspective, EMR wins hands down as typed trumps handwritten notes in the vast majority of cases. In fact, as we become more comfortable using technology, I believe that the quality of penmanship further deteriorates. Narrative vs. structured data recorded in the EMR? While I fully understand the need for discrete data in the EMR in order to graph, search, and analyze, I much prefer reading a narrative note, particularly if it is detailed. Trying to reconstruct a clinical encounter from a series of bullet points may work for common conditions such as UTIs or Hypertension monitoring, but it is extremely difficult for mental health problems or multi-system disease. Some of the patient summaries and printouts generated by EMRs are dreadful both in terms of format and content. Sifting through reams of discrete lab results, each on a separate line, or encounters that do not make any logical sense is very frustrating.

An article on AmericanEHR.com titled, “Are You Proud of Your Documentation Using an EHR?” drew some insightful feedback. Personally, I do not believe that technology is the problem. It is more related to how that technology is being used, whether the templates and clinical encounters have been optimized for data entry, the ease of use of the EMR regarding data entry, and whether the system can generate a record that is as good, if not better, than a well-written narrative note.

What is your experience? Are you satisfied with the documentation in your EMR? If not, what would you change to make it better?

EMRs have now been used in Canada for some time — in some practices, 10 years or more — but, more importantly, by a large number of non-techy middle and late adopters. These are the physicians who have adopted EMRs because they saw the writing on the wall that an EMR will be the future primary mechanism in which patient information is recorded and information is generated and shared. EMRs are also complex software applications and as anyone who has used an EMR will attest, they certainly are not perfect. Each has its own strengths and weaknesses and all have their gaps. Some of the gaps are related to functionality that should be in the EMR, but is not built in — the responsibility of the vendor. Other gaps are completely out of the control of the vendor and are related to provincial or national requirements such as standards for data sharing, processes for referral and consultation, etc.

That being said, from the user's perspective these differences are immaterial. You need the tools at your fingertips that allow you to do the job at hand. If you have used your EMR (or EMRs) for one year or more (i.e. you are through the implementation and orientation phases), what are the gaps in your system?

To provide some broad categories, these gaps could be related to any of following:

In the five years from 2008 to 2012, E-Prescribing in the United States became mainstream. According to health information network operator SureScripts, in 2008 only 1 in 10 physicians E-Prescribed. By 2012, this number had increased to greater than 2 in 3 physicians E-Prescribing (69% of office-based physicians). Click on the image to view progress during this period.

It is important to note that the adoption of E-Prescribing in the United States has taken place rapidly, with 380,000 office-based physicians actively prescribing — this in a country with 5 times the number of state jurisdictions and 10 times the number of physicians as Canada. So, how did they do it and what lessons can we learn?

The Canadian Medical Association and the Canadian Pharmacists Association released a joint statement on E-Prescribing in May 2013. The Statement highlights the principles, vision, and benefits of E-Prescribing. In the document, the definition is as follows: “e-Prescribing is the secure electronic creation and transmission of a prescription between an authorized prescriber and a patient’s pharmacy of choice, using clinical Electronic Medical Record (EMR) and pharmacy management software.”

In the U.S., E-Prescribing is defined more broadly than in Canada. I believe this to be largely responsible for setting expectations and determining measures of success in the U.S. program. The Clinician’s Guide to E-Prescribing (developed by The Center for Improving Medication Management) defines E-Prescribing as the use of a computer, handheld device, or other hardware with software that allows prescribers to:

With a patient’s consent, electronically access information regarding a patient’s drug benefit coverage and medication history.

Electronically transmit the prescription to the patient’s choice of pharmacy.

While there may be different approaches in Canada regarding statement 1, namely the need to access information regarding a patient’s drug benefit coverage, the important differentiator is the description of a continuum of care, as in the last statement. Prescribe and transmit are just two components of a system that needs to function as a closed-loop in order to be successful. If we do not include electronically transmitted prescription renewal requests in the definition, key functionality (e.g. the need to reconcile the prescription renewal with prescribed medications — particularly if additional prescriptions have been written by a different prescriber — will not be built into the core systems.

We are on the right track; however, the U.S. must have done something right to have achieved the high levels of adoption of E-Prescribing that are currently in place. The definition is just a small piece of a big and complex system, but it is an important component.

My recommendation is to revisit the definition of E-Prescribing and ensure that it is sufficiently comprehensive that success can support the entire medication management process — prescribe, transmit, dispense, administer, renew, and monitor. If this is not done in advance, we may achieve 100% success, but end up with only half the needed systems and processes.

Share your thoughts on E-Prescribing. Should we revisit the definition or do you think we have enough to achieve our goals in Canada? Click on the “Comments” link below.

In a CMAJ article titled “Big data’s dirty secret” (Webster, June 6), the author highlights the barriers to leveraging big data in Canada and points to “technological limitations stemming from mismanagement by government e-health agencies and commercial turf battles” as an important cause of this problem. Webster also cites others who have had challenges with the data generated from EMRs currently used in Canada including Patricia Sullivan-Taylor, manager of primary health care information (Canadian Institute for Health Information) and Alex Mair, director of health system use for Canada Health Infoway, the organization responsible for developing and implementing Canada’s health Infostructure. According to Sullivan-Taylor, each EMR system produces different types of data, something that was not resolved before EMRs were installed in physician offices. Mair also acknowledges that progress has been slow in using “big data” and the resultant inability to gain insights into clinical data is a key gap for clinicians.

While I agree with many of the concepts and comments in the article, I would like to add further clarifications. Mario Bojilov recently published a concise overview of big data and defines it as “data sets that — due to their size (volume), the speed they are created
with (velocity), and the type of information they contain (variety) — are
pushing the existing infrastructure to its limits”. Big data, in healthcare, seems to have become synonymous with data analytics, “a process of inspecting, cleaning, transforming, and modeling data with the goal of highlighting useful information, suggesting conclusions, and supporting decision making” (Wikipedia); however, I belive it is misleading to broadly think of EMR systems in physician offices as generators of big data. While large networks of clinical users on a common EMR can certainly generage large amounts of data, many of the current limitations apply equally to “small data” as they do to the high velocity, volume, and variety of big data.

Simply put, there are many EMR systems that cannot effectively be used to generate insights from small collections of data, never mind big cumulative data sets. For example, EMR systems that record information in narrative format (not as discrete data) are unable to generate analytic reports for patient populations because they were not designed to function as analytical tools right from their early genesis. EMRs that collect data in highly structured formats are able to output information that can be queried using analytical tools that are either built into the EMR systems or third-party software that is able to take data sets generated by EMRs and provide data analysis as an integrated functionality or outside of the clinical system. However, taking data from multiple EMRs and merging it together is not possible. Why, you might ask? Well, because each EMR system has been built using proprietary data structures without any coordinated national effort to define national data standards for EMRs. The reason that Interac bank machines work is that all the messages and data structures are the same — irrespective of which bank you may use. The same cannot be said for EMR data. One of the great technology successes of the UK’s defunct National Program for IT was a project called GP2GP through which a patient’s electronic health records can be transferred directly and securely between GP practices. This was made possible because of standardized data structures.

As provincial EMR programs begin to wind down, starting with Alberta in 2014, and provinces transition to a support and optimization role for users of EMRs, the lack of data standards for EMRs is going to become a greater and greater problem. Short of completely redesigning existing EMRs using the same data structures and standards for all systems, it will be a nearly impossible task to reverse modify the EMRs used by 70% of target physicians. We are stuck with what we currently have. The policy failures of the past — insufficient support for clinical leadership in the early stages of EMRs and a lack of focus in developing and implementing standarized data structures and clinical messages for EMR systems (nationally and provincially) — have created the current pickle we are now in.

Before we can fully utilize and gain insights from big data, we had better sort out small data in EMRs. This needs to begin with a focus on data quality, the management of patient populations at the practice level, and ensuring that the clinical messages passed between EMRs use nationally-accepted standards so that data is interoperable and usable by other systems.

What do you think? Are there other priorities to consider in order to make data more usable by multiple EMRs? To add your thoughts, click on the “Comments” link below.

Writing a prescription is one of the most fundamental tasks that physicians do on a daily basis. However, whether patients take their medication is difficult to determine. According to an article in Mayo Clinic Proceedings (2011), approximately 50% of patients do not take their medication as prescribed. There are many reasons for poor medication adherence: complex drug regimens, communication issues between doctor and patient, and too many providers involved in patient care, resulting in confusion and inadequate explanation of side effects. Thus, there is no single solution to this problem. EMRs are very good at tracking what has been prescribed for patients; however, they suffer the same limitations after the prescription has been written.

EMRs provide access to more comprehensive information at the point of care regarding medication usage and potential interactions that can be identified before writing the prescription. In this way, they are able to contribute to medication adherence; however, there are some very interesting technologies that allow real-time tracking of medication adherence, including the following:

Proteus Digital Health — ingestable sensors that are integrated with medications and transmit information to a sensor that is placed on the abdomen. The sensors are powered by digestive enzymes and data captured in the abdominal sensor can be transmitted to a device such as a smartphone.

Smart pill bottles, such as those developed by AdhereTech. The bottles are wirelessly enabled and transmit data when the bottle has been opened. A sensor inside the bottle keeps track of how many pills or how much liquid is remaining and transmits this data to a central source where it is compared against the patient’s medication regimen and then sends the patient a reminder or notification if they have forgotten to take their meds or have not taken the correct dose.

A mobile app developed by Mango Health that allows users to keep track of their medications and earn points for which a variety of gifts can be claimed.

This is a very dynamic and exciting area that will see significant growth in the next few years. Although these types of technologies are still in testing phases, imagine a future where you could look at your patient’s medication profile in your EMR and be able to see whether they have been adherent to their medication regime from data that has been transmitted by pill bottles to your system.

Will this help or hinder the care of patients? Do you see this type of technology being disruptive or additive to your daily workflow? To add your thoughts, click on the “Comments” link below.

Patient data is increasingly available to clinicians through a wide variety of tools and form factors. As high-speed Internet through Wifi and 4G becomes ubiquitous, access and speed are no longer an issue. In parallel, physicians are increasingly using EMRs as their primary tool to document, manage, and treat patients. As a result, it is not surprising that they should want to access clinical data using a mobile phone or tablet. Blackberry appears to be back in contention as a device for business users, but the majority of mobile devices used by doctors are smartphones — with the Apple iPhone the device of choice.

A recent survey conducted by AmericanEHR Partners, with 702 verified physicians within the
U.S. between October 10, 2012, and December 8, 2012, revealed the following:

The most popular brand of smartphone used across respondents was Apple’s iPhone.

The most popular clinical apps were Epocrates, Medscape, and MedCalc.

Twice as many non-EMR physicians use a traditional mobile phone compared to EMR users.

One-quarter of non-smartphone users intend to buy a smartphone in the next six months.

Both EMR and non-EMR users spend 15–16 hours a week on their smartphone.

35% of respondents use their smartphone to research information on medications daily.

The least common smartphone activity for business purposes is Tweeting (5%).

I recently spent some time in Singapore working with a team on the national medication and allergy systems. As a result, I was able to observe how the public uses mobile devices for everyday access. What surprised me were the number of people (physicians and non-physicians) who carried larger phones such as the Samsung Galaxy Note. Called “Phablets”, these devices merge the mobility of the smartphone with the screen size of a tablet and provide greater screen size, which is critical for viewing a large amount of information without the need to scroll. For the past year, I have been carrying an iPad mini when I travel or if I am unable to carry a laptop with me. Tethering the tablet to my iPhone, I am able to access the Internet (as well as any other app that requires a login).

An exciting evolution that we will see more prevalent in the next 12–24 months is remote access to one’s EMR using a mobile phone or tablet. A September 2012 blog post on CanadianEMR titled, “Should I Access My EMR Using a Mobile Phone?” highlighted security and access precautions as well as advice to reduce the risk of health data breaches.

If you have an EMR, or are considering implementation and would like to have remote access through your phone or tablet, speak to your EMR vendor (or potential systems provider) about mobile apps or whether they have a preferred mechanism for access to the EMR using a web browser on small form-factor devices.

Do you have any experience using your mobile phone to access your EMR? Click on the “Comments” link to share your thoughts or comments.

To purchase a copy of AmericanEHR Mobile Use in the Medical Space, please click here.

One of the questions that I am frequently asked about EMR systems is to describe what I see as the future of EMRs in Canada. With many provinces now achieving a critical mass of EMR users, we will now be able to do things with EMRs that in the past were very difficult to achieve. There are some key EMR features that I would like to highlight.

Usability: EMRs will get easier to use. This will take place at variable rates depending on which EMR system you are using. Those with active user groups who can provide constructive feedback to vendors will benefit the most. As the focus shifts from getting physicians to adopt their first EMR system, to EMR optimization, it will become more important for vendors to focus on the usability of their systems and they will dedicate a greater proportion of their resources to improving their products.

Mobility: EMRs are traditionally accessed using a laptop or desktop computer. The laptop is sometimes carried by the physician from room to room or can be attached to a wall mount or mobile cart. Because it is best to access one’s EMR using a large monitor due to the large amounts of information that need to be accessed, it is not practical in many settings to use tablets or even smartphones on a consistent basis in the examination room. However, outside of the medical office, the needs are completely different. When accessing one’s EMR remotely, the ability to view specific information using a mobile app, or even a browser with secure access, are extremely valuable to clinicians who may need to look up a lab result or write a prescription. The next phase of EMR use will see a much wider range of mobile apps for both look-up purposes and the management of medications and clinical notes.

Security: Some clinicians are likely to use regular email for communication with colleagues and patients. This is not ideal from a security perspective, but often practicality trumps security, particularly if the process is time-consuming and makes the messaging more difficult. The next phase of EMRs will incorporate easier-to-use and more streamlined secure communications to transmit information to colleagues (secure referral or consultation) or to communicate with patients through integrated patient portals.

Analytics: As physicians move through the early challenges of EMR implementation and achieve a level of optimization of their internal office setting, they will become far more focused on the ability of EMRs to improve patient care. This will dovetail with pay-for-performance programs in which provincial programs will expect to see measurable benefit for the dollars invested in healthcare. In a paper-based practice, this would be extremely difficult to accomplish; however, using an EMR that incorporates analytic capabilities, it will be possible to generate status reports for populations or individual patients with a click of button.

What other features do you think will be prominent in EMRs in the next 5–10 years? Add your thoughts or comments below.